Clinical UM Guideline


Subject:Anesthesia Services and Moderate (“Conscious”) Sedation
Guideline #:   CG-MED-21Current Effective Date:  07/09/2013
Status:ReviewedLast Review Date:   05/09/2013

Description

Anesthesia services include all services associated with the administration and monitoring of analgesia or anesthesia in order to produce partial or complete loss of sensation. Examples of various methods of anesthesia include general anesthesia, regional anesthesia, monitored anesthesia care (MAC), moderate sedation ("conscious sedation"), and local infiltration or topical application. 

NOTE:  This document does not address anesthesia services during gastrointestinal endoscopic procedures. See: CG-MED-34 Anesthesia Services for Gastrointestinal Endoscopic Procedures.

This document addresses the medical necessity of anesthesia services. It does not address whether or not reimbursement is provided for the anesthesia service. This document is not intended to explain the billing and reimbursement of anesthesia.   

Clinical Indications

Medically Necessary: 

General Anesthesia or Regional Anesthesia
Administration of general or regional anesthesia is considered medically necessary when both of the following criteria are met:

  1. The services are provided by an individual other than the attending physician performing the procedure; AND
  2. Alternative types of anesthesia, sedation, or analgesia are not appropriate. 

If general or regional anesthesia is requested for a procedure typically not requiring either of these levels of anesthesia service, a medical necessity review will be performed. This review will assess not only the procedure involved, but also other individual-specific issues, such as age, mental status, ability to cooperate, co-morbid conditions, and general medical status.

Monitored Anesthesia Care (MAC)
Monitored anesthesia care (MAC) is considered medically necessary when all of the following criteria are met:

  1. MAC is requested by the attending physician; AND
  2. The services are provided by an individual other than the attending physician performing the procedure; AND
  3. Qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists) administering monitored anesthesia care are continuously present to monitor the individual and provide anesthesia care; AND
  4. The individual's medical condition requires medical direction or supervision of the anesthetic to ensure control of the sedation, medication, and airway, and to prevent sudden changes in condition from disrupting the procedure and placing the individual at risk; AND
  5. Constant monitoring of the individual's vital signs is provided to anticipate the need for general anesthesia administration or for the treatment of adverse physiologic reactions such as hypotension, excessive pain, difficulty breathing, arrhythmias, adverse drug reactions, etc. In addition, the possibility that the procedure may become more extensive, or result in unforeseen complications, requires comprehensive monitoring or anesthetic intervention; AND
  6. Appropriate documentation is available to reflect pre- and post-anesthetic evaluations and intraoperative monitoring.

Anesthesia Services including MAC
For surgical procedures which do not usually require anesthesia services, anesthesia services including monitored anesthesia care (MAC) are considered medically necessary when the individual's condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure, and is so documented. The medical condition must be significant enough to impact the need to provide anesthesia services including MAC. Complex procedures and procedures in high-risk individuals may justify the use of an anesthesiologist or anesthetist to provide conscious sedation or deep sedation. See Appendix for physical status classifications. The presence of a stable, treated condition of itself is not necessarily sufficient.

Moderate ("Conscious") Sedation
Moderate sedation ("conscious sedation") ordered by the attending physician and administered by the surgeon or physician performing the procedure or an independent trained practitioner is considered medically necessary when alternative types of anesthesia, sedation, or analgesia are not appropriate.  

Local Anesthesia
The administration of local anesthesia is considered medically necessary when alternative types of anesthesia, sedation, or analgesia are not appropriate. 

Standby Anesthesia Services
Standby anesthesia service is when the anesthesiologist would be immediately available if a clinical need should arise but the anesthesiologist may be elsewhere performing other duties. Stand-by anesthesia is considered medically necessary when a procedure, which does not normally require anesthesia services, has a significant potential for catastrophic complications or potential for the need of other intervention that would require immediate availability of general anesthesia.

Not Medically Necessary:

Anesthesia services are considered not medically necessary for all other indications.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
00100-00222Anesthesia for procedures on the head [includes codes 00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222]
00300-00352Anesthesia for procedures on the neck [includes codes 00300, 00320, 00322, 00326, 00350, 00352]
00400-00474Anesthesia for procedures on the thorax [includes codes 00400, 00402, 00404, 00406, 00410, 00450, 00452, 00454, 00470, 00472, 00474]
00500-00580Anesthesia for intrathoracic procedures [includes codes 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567, 00580]
00600-00670Anesthesia for procedures on spine and spinal cord [includes codes 00600, 00604, 00620, 00622, 00625, 00626, 00630, 00632, 00634, 00635, 00640, 00670]
00700-00797Anesthesia for procedures on upper abdomen [includes codes 00700, 00702, 00730, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797]
00800-00882Anesthesia for procedures on lower abdomen [includes codes 00800, 00802, 00820, 00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882]
00902-00952Anesthesia for procedures on perineum [includes codes 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952]
01112-01190Anesthesia for procedures on pelvis [includes codes 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190]
01200-01274Anesthesia for procedures on upper leg [includes codes 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274]
01320-01444Anesthesia for procedures on knee and popliteal area [includes codes 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444]
01462-01522Anesthesia for procedures on lower leg [includes codes 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522]
01610-01682Anesthesia for procedures on shoulder and axilla [includes codes 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682]
01710-01782Anesthesia for procedures on upper arm and elbow [includes codes 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782]
01810-01860Anesthesia for procedures on forearm, wrist, and hand [includes codes 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860]
01905-01953Anesthesia for radiological procedures, burn excisions or debridement [includes codes 01916, 01920, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01953]
01958-01969Anesthesia for obstetric procedures [includes codes 01958, 01960, 01961, 01962, 01963, 01965, 01966, 01967, 01968, 01969]
01990-01999Other anesthesia procedures [includes codes 01990, 01991, 01992, 01996, 01999]
62310Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic
62311Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar, sacral (caudal)
62318Injection(s), including catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s)(including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic
62319Injection(s), including catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s)(including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar, sacral (caudal)
64400-64450Introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic [when used for regional anesthesia; includes codes 64400, 64402, 64405, 64408, 64410, 64412, 64413, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, 64450]
99100Anesthesia for patient of extreme age, younger than 1 year and older than 70
99116Anesthesia complicated by utilization of total body hypothermia
99135Anesthesia complicated by utilization of controlled hypotension
99140Anesthesia complicated by emergency conditions (specify)
99143-99145Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status [includes codes 99143, 99144, 99145]
99148-99150Moderate sedation services (other than those services described by codes 00100-01999) provided by a physician or other qualified healthcare professional other than the health care professional performing the diagnostic or therapeutic service that the sedation supports [includes codes 99148, 99149, 99150]
  
 CPT Physical Status Modifiers
P1A normal healthy patient (Class I)
P2A patient with mild systemic disease (Class II)
P3A patient with severe systemic disease (Class III)
P4A patient with severe systemic disease that is a constant threat to life (Class IV)
P5A moribund patient who is not expected to survive without the operation (Class V)
  
HCPCS 
 HCPCS Anesthesia Modifiers
AAAnesthesia services performed personally by anesthesiologist
ADMedical supervision by a physician: more than four concurrent anesthesia procedures
G8Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure
G9Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition
QKMedical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals
QSMonitored anesthesia care service
QXCRNA service: with medical direction by a physician
QYMedical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist
QZCRNA service: without medical direction by a physician
  
ICD-9 Diagnosis 
 All diagnoses
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
 All diagnoses
  
Discussion/General Information

Anesthesia services are provided by or under the supervision of a physician. Services consist of the administration of an anesthetic agent in various types of anesthesia.

Types of Anesthesia and Anesthesia Services 

Anesthesia Service by the Surgeon: Anesthesia services personally furnished by the physician performing the surgical, therapeutic or diagnostic procedure are considered an integral component of the primary procedure. This may include local injections, regional blocks, and intravenous medication. General anesthesia administered and monitored by the surgeon is not considered medically appropriate.

Balanced Anesthesia: Anesthesia that uses a combination of drugs, each in an amount sufficient to produce its major or desired effect to the optimum degree and keep its undesirable or unnecessary effects to a minimum. 

Bier Block/Bier's Local Anesthesia: Regional anesthesia produced by intravenous injection, used for surgical procedures on the arm below the elbow or the leg below the knee; performed in a bloodless field maintained by a pneumatic tourniquet that also prevents the anesthetic from entering the systemic circulation. 

Brachial Plexus Block/Brachial Plexus Anesthesia: Regional anesthesia of the shoulder, arm, and hand by injection of a local anesthetic into the brachial plexus. 

Caudal Block/Caudal Anesthesia: Regional anesthesia produced by injection of a local anesthetic into the caudal or sacral canal. 

Closed Circuit Anesthesia: Inhalation anesthesia maintained by the continuous rebreathing of a relatively small amount of the anesthetic gas and a basal amount of oxygen, normally used with an absorption apparatus for the removal of carbon dioxide. 

Endobronchial Anesthesia: Anesthesia produced by introduction of a gaseous mixture through a slender tube placed in the large bronchus. 

Endotracheal Anesthesia: Anesthesia produced by introduction of a gaseous mixture through a wide-bore tube inserted into the trachea through either the mouth or the nose. 

Epidural Anesthesia: Regional anesthesia produced by injection of the anesthetic agent between the vertebral spines and beneath the ligamentum flavum into the epidural space. 

General Anesthesia: A reversible state of unconsciousness and the inability to perceive pain, produced by anesthetic agents, with absence of pain sensation over the entire body and a greater or lesser degree of muscular relaxation; the drugs producing this state can be administered by inhalation, intravenously, intramuscularly, rectally, or via the gastrointestinal tract. 

Hypotensive Anesthesia: Anesthesia accompanied by the deliberate lowering of the blood pressure, a procedure said to reduce blood loss and improve usability of the surgical field. 

Hypothermic Anesthesia: Anesthesia accompanied by the deliberate lowering of body temperature. 

Inhalation Anesthesia: Anesthesia produced by the inhalation of vapors of a volatile liquid or gaseous anesthetic agent.

Insufflation Anesthesia: Anesthesia produced by blowing a mixture of gases or vapors through a tube introduced into the respiratory tract.

Intercostal Anesthesia: Anesthesia produced by blocking intercostal nerves with a local anesthetic. 

Intranasal Anesthesia: Local anesthesia produced by insertion into the nasal fossae of pledgets soaked in a solution of an anesthetic agent which is effective after topical application, or by insufflation of a mixture of anesthetic gases or vapors through a tube introduced into the nose. 

Intraoral Anesthesia: Anesthesia produced within the oral cavity by injection, spray, pressure, etc. 

Intrathecal Anesthesia: Anesthesia produced by injection of an anesthetic solution into either the subarachnoid or subdural space. 

Intravenous Anesthesia: Anesthesia produced by introduction of an anesthetic agent into a vein.

Local Anesthesia: Anesthesia confined to one area of the body.

Moderate ("Conscious") Sedation: Involves the administration of medication with or without analgesia to achieve a state of depressed consciousness while maintaining the individual's ability to respond to stimulation. Moderate ("conscious") sedation is administered by the surgeon or physician performing the procedure or an independent trained practitioner for the purpose of assisting the physician in monitoring the individual's level of consciousness and physiological status. It includes pre- and post- sedation evaluations, administration of the sedation and monitoring of the cardiorespiratory function. Cardiorespiratory functions monitored include heart rate, blood pressure and oxygen level.

Monitored Anesthesia Care (MAC): MAC was developed in response to the shift to providing more surgical and diagnostic services in an ambulatory, outpatient or office setting without the use of the traditional general anesthetic. Accompanying this, there has been a change in the provision of anesthesia services from the traditional general anesthetic to a combination of local, regional and certain consciousness altering drugs. This type of anesthesia is referred to as MAC if directly provided by anesthesia personnel. Based on the American Society of Anesthesiologists' standards for monitoring, MAC should be provided by qualified anesthesia personnel (anesthesiologists or qualified anesthetists such as certified registered nurse anesthetists). These individuals must be continuously present to monitor and provide anesthesia care.

As described by the ASA's Position on Monitored Anesthesia Care (2008):

Monitored anesthesia care is a specific anesthesia service for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include the nature of the procedure, the patient's clinical condition or the potential need to convert to a general or regional anesthetic.

Monitored anesthesia care includes all aspects of anesthesia care – a preprocedure visit, intraprocedure care and postprocedure anesthesia management. During monitored anesthesia care, the anesthesiologist provides or medically directs a number of specific services, including but not limited to:

Monitored anesthesia care may include varying levels of sedation, analgesia, and anxiolysis as necessary. The provider of monitored anesthesia care must be prepared and qualified to convert to general anesthesia when necessary. If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required.

Patient-Controlled Analgesia (IV PCA): A method of pain control which allows the individual to control their own dosage of analgesia received. It involves the use of a patient-controlled analgesia (PCA) infusion pump which delivers the desired amount of medication through a conventional intravenous route or via an implantable intravenous catheter inserted in subcutaneous tissue.

Regional Anesthesia: Anesthesia that involves the use of local anesthetic solutions(s) to produce circumscribed areas of loss of sensation. This includes spinal, epidural, nerve, field and extremity blocks. Spinal and epidural anesthesia is produced by injection of local anesthetic solution near the spinal canal, which interrupts sensation from the legs or abdomen.

Sacral Anesthesia: Anesthesia produced by injection of a local anesthetic into the extradural space of the sacral canal.

Saddle Block Anesthesia: A type of sacral anesthesia produced in a region corresponding roughly with the area of the buttocks, perineum, and inner aspects of the thighs, by introducing the anesthetic agent low in the dural sac. 

Spinal Anesthesia: 1) Regional anesthesia produced by injection of a local anesthetic into the subarachnoid space around the spinal cord. 2) Loss of sensation due to a spinal lesion.

Standby Anesthesia: Anesthesia standby occurs when the anesthesiologist, or the CRNA, is available in the facility in the event he or she is needed for a procedure that requires anesthesia (e.g., available in the facility in case of obstetric complications - breech presentation, twins, and trial of instrumental delivery), but is not physically present or providing services. Standby anesthesia is not direct care (i.e., it is a standby service without direct hands-on contact).

Surgical Anesthesia: That degree of anesthesia at which pain is completely relieved and surgery may be performed; ordinarily used to designate such depth of general anesthesia.

Topical Anesthesia: Anesthesia produced by application of a local anesthetic directly to the area involved.

American Society of Anesthesiologists Levels of Sedation/Analgesia* 

Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate Sedation/Analgesia ("Conscious Sedation") is a drug-induced depression of consciousness during which patients respond purposefully** to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. 

Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

American Society of Anesthesiologists Definition of General Anesthesia

General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue*** patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia ("Conscious Sedation") should be able to rescue*** patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue*** patients who enter a state of General Anesthesia.

* Monitored Anesthesia Care does not describe the continuum of depth of sedation, rather it describes "a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure."

** Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

***Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society of Anesthesiologists. ASA Physical Status Classification System. For additional information visit the ASA website: http://www.asahq.org. Accessed on February 22, 2013.
  2. American Society of Anesthesiologists. ASA Position on Monitored Anesthesia Care. (Approved by the House of Delegates on October 21, 1986, and last updated on September 2, 2008). For additional information visit the ASA website: http://www.asahq.org. Accessed on February 22, 2013.
  3. American Society of Anesthesiologists. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia* (Approved by ASA House of Delegates on October 27, 2004, and amended on October 21, 2009). For additional information visit the ASA website: http://www.asahq.org. Accessed on February 22, 2013.
  4. American Society of Anesthesiologists. Statement on granting privileges to non-anesthesiologist physicians for personally administering or supervising deep sedation. (Approved by the ASA House of Delegates on October 18, 2006, and amended on October 17, 2012). For additional information visit the ASA website: http://www.asahq.org. Accessed on February 22, 2013.
  5.  American Society of Anesthesiologists. Statement on regional anesthesia. (Approved by the ASA House of Delegates on October 12, 1983, and last amended on October 17, 2012). For additional information visit the ASA website: http://www.asahq.org. Accessed on February 22, 2013.
  6. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002; 96(4):1004-1017.
Index

Anesthesia Services
Conscious Sedation
General Anesthesia
Moderate Sedation
Monitored Anesthesia Care (MAC)
Regional Anesthesia

History
StatusDateAction
Reviewed05/09/2013Medical Policy & Technology Assessment Committee (MPTAC) review. References updated.
Reviewed05/10/2012MPTAC review. References updated.
Reviewed05/19/2011MPTAC review. References updated.
Reviewed05/13/2010MPTAC review. Discussion and references updated.
 01/01/2010Updated coding section with 01/01/2010 CPT changes; removed CPT 01632 deleted 12/31/2009.
Reviewed05/21/2009MPTAC review. Discussion, coding and references updated. Place of service section removed.
Revised05/15/2008MPTAC review. Added a statement for when anesthesia services are not medically necessary. References and appendix updated. Coding updated with 01/01/2008 CPT updates; removed CPT 01905 deleted 12/31/2007.
Reviewed05/17/2007MPTAC review. References updated.
Revised06/08/2006MPTAC review. Document title revised. Term conscious sedation updated to moderate sedation per ASA guidelines. Updated definition of MAC per ASA guidelines. Indications for anesthesia services during gastrointestinal endoscopic procedures removed. References updated. 
Revised03/23/2006MPTAC review. Updated language for regional anesthesia. Revision per recommendation from American Society of Anesthesiologists.
 01/01/2006Updated coding section with 01/01/2006 CPT/HCPCS changes.
Revised09/22/2005MPTAC review. Revision based Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 No document
WellPoint Health Networks, Inc.

04/28/2005

Definition vii

Anesthesia Services
    
Appendix

American Society of Anesthesiology Physical Status Classifications:

P1 A normal healthy patient    

P2 A patient with mild systemic disease    

P3  A patient with severe systemic disease    

P4 A patient with severe systemic disease that is a constant threat to life    

P5 A moribund patient who is not expected to survive without the operation    

P6 A declared brain-dead patient whose organs are being removed for donor purposes